A nurse is preparing to suction secretions from a patient who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Choice A rationale

This statement is incorrect. Advance directives do not allow the court to overrule an adult client’s refusal of medical treatment. They are legal documents that provide instructions for medical care and only go into effect if the individual cannot communicate their own wishes.

Choice B rationale

This statement is correct. Advance directives indicate the form of treatment a client is willing to accept in the event of a serious illness. They allow individuals to express their preferences about medical treatment at some point in the future, should they become unable to communicate their wishes.

Choice C rationale

This statement is incorrect. Advance directives do not permit a client to withhold medical information from health care personnel. They are used to communicate the individual’s wishes about medical treatment to their healthcare providers and family.

Choice D rationale

This statement is incorrect. Advance directives do not specifically allow health care personnel in the emergency department to stabilize a client’s condition. They are used to guide choices for doctors and caregivers if the individual is terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.

Choice A rationale: Initiating a cardiac enzyme panel can help determine if the client has had a heart attack. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first. An ECG can provide immediate information, while a cardiac enzyme panel takes longer to return results.

Choice B rationale: Starting intravenous fluid therapy may be necessary depending on the client’s hydration status and overall condition. However, it is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.

Choice C rationale: Providing pain relief medication may be necessary if the client is in pain. However, the client’s primary complaint is chest tightness and difficulty breathing, not pain. Therefore, addressing the potential cardiac issue is the priority.

Choice D rationale: The client’s symptoms of sudden shortness of breath, chest tightness, and anxiety, along with her history of hypertension and diabetes, are concerning for a possible cardiac event. An electrocardiogram (ECG) can provide immediate information about the heart’s electrical activity and help identify if the client is experiencing a heart attack or other cardiac event. This should be the first action taken to quickly identify the cause of the client’s symptoms and initiate appropriate treatment.

Choice E rationale: Performing a comprehensive physical assessment is an important part of nursing care. However, in this situation, the client’s symptoms indicate a need for immediate intervention to address her potential cardiac issue.

Choice F rationale: Monitoring the client’s blood glucose levels is important given her history of diabetes. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.